SB-0466, As Passed House, December 14, 2006

SUBSTITUTE FOR

SENATE BILL NO. 466

     A bill to amend 1939 PA 280, entitled

"The social welfare act,"

by amending section 111b (MCL 400.111b), as amended by 2000 PA 187.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

     Sec. 111b. (1) As a condition of participation, a provider

shall meet all of the requirements specified in this section except

as provided in subsections (25), (26), and (27).

     (2) A provider shall comply with all licensing and

registration laws of this state applicable to the provider's

practice or business. For a facility that is periodically inspected

by a licensing authority, maintenance of licensure constitutes

compliance.

     (3) A provider shall be certified, if the provider is of the

type for which certification is required by title XVIII or XIX.

     (4) A provider shall enter into an agreement of enrollment

specified by the director.

     (5) A provider who renders a reimbursable service described in

section 109 to a medically indigent individual shall provide the

individual with service of the same scope and quality as would be

provided to the general public.

     (6) A provider shall maintain records necessary to document

fully the extent and cost of services, supplies, or equipment

provided to a medically indigent individual and to substantiate

each claim and, in accordance with professionally accepted

standards, the medical necessity, appropriateness, and quality of

service rendered for which a claim is made.

     (7) Upon request and at a reasonable time and place, a

provider shall make available any record required to be maintained

by subsection (6) for examination and photocopying by authorized

agents of the director, the department of attorney general, or

federal authorities whose duties and functions are related to state

programs of medical assistance under title XIX. If a provider

releases records in response to a request by the director made

pursuant to  under section 111a(13) or in compliance with this

subsection, that provider is not civilly liable in damages to a

patient or to another provider to whom, respectively, the records

relate solely, on account of the response or compliance.

     (8) A provider shall retain each record required to be

maintained by subsection (6) for a period of  6  7 years after the

date of service. A provider who no longer personally retains the

records due to death, retirement, change in ownership, or other

reason, shall  insure  ensure that a suitable person retains the

records and provides access to the records as required in

subsection (7).

     (9) A provider shall require, as a condition of  any  a

contract with a person, sole proprietorship, clinic, group,

partnership, corporation, association, or other entity, for the

purpose of generating billings in the name of the provider or on

behalf of the provider to the  state department, that the person,

partnership, corporation, or other entity, its representative,

successor, or assignee, retain for not less than  6  7 years,

copies of all documents used in the generation of billings,

including the certifications required by subsection (17), and, if

applicable, computer billing tapes  when  if returned by the  state

department.

     (10) A provider shall submit all claims for services rendered

under the program on a form or in a format and with the supporting

documentation specified and required by the director under section

111a(7)(c) and by the commissioner of insurance under section 111i.

Submission of a claim or claims for services rendered under the

program does not establish in the provider a right to receive

payment from the program.

     (11) A provider shall submit initial claims for services

rendered within 12 months after the date of service, or within a

shorter period that the director may establish or that the

commissioner of insurance may establish under section 111i. The

director shall not delegate the authority to establish a time

period for submission of claims under this subsection. Except as

otherwise provided in section 111i, the director, with the

consultation required by section 111a, may prescribe the conditions

under which a provider may qualify for a waiver of the time period

established  pursuant to  under this subsection with respect to a

particular submission of a claim. Neither this state nor the

medically indigent individual is liable for payment of claims

submitted after the period established  pursuant to  under this

subsection.

     (12) A provider shall not charge the state more for a service

rendered to a medically indigent individual than the provider's

customary charge to the general public or another third party payer

for the same or similar service.

     (13) A provider shall submit information on estimated costs

and charges on a form or in a format and at times that the director

may specify and require  pursuant  according to section 111a(16).

     (14) Except for copayment authorized by the  state department

and in conformance with applicable state and federal law, a

provider shall accept payment from the state as payment in full by

the medically indigent individual for services received. A provider

shall not seek payment from the medically indigent individual, the

family, or representative of the individual for either of the

following:

     (a) Authorized services provided and reimbursed under the

program.

     (b) Services determined to be medically unnecessary in

accordance with professionally accepted standards.

     (15) A provider may seek payment from a medically indigent

individual for services not covered nor reimbursed by the program

if the individual elected to receive the services with the

knowledge that the services would not be covered nor reimbursed

under the program.

     (16) A provider promptly shall notify the director of a

payment received by the provider to which the provider is not

entitled or that exceeds the amount to which the provider is

entitled. If the provider makes or should have made notification

under this subsection or receives notification of overpayment under

section 111a(17), the provider shall repay, return, restore, or

reimburse, either directly or through adjustment of payments, the

overpayment in the manner required by the director. Failure to

repay, return, restore, or reimburse the overpayment or a

consistent pattern of failure to notify the director shall

constitute a conversion of the money by the provider.

     (17) As a condition of payment for services rendered to a

medically indigent individual, a provider shall certify that a

claim for payment is true, accurate, prepared with the knowledge

and consent of the provider, and does not contain untrue,

misleading, or deceptive information. A provider is responsible for

the ongoing supervision of an agent, officer, or employee who

prepares or submits the provider's claims. A provider's

certification required under this subsection shall be prima facie

evidence that the provider knows that the claim or claims are true,

accurate, prepared with his or her knowledge and consent, do not

contain misleading or deceptive information, and are filed in

compliance with the policies, procedures, and instructions, and on

the forms established or developed  pursuant to  under this act.

Certification shall be made in the following manner:

     (a) For an invoice or other prescribed form submitted directly

to the  state department by the provider in claim for payment for

the provision of services, by an indelible mark made by hand,

mechanical or electronic device, stamp, or other means by the

provider, or an agent, officer, or employee of the provider.

     (b) For an invoice or other form submitted in claim for

payment for the provision of services submitted indirectly by the

provider to the  state department through a person, sole

proprietorship, clinic, group, partnership, corporation,

association, or other entity that generates and files claims on a

provider's behalf, by the indelible written name of the provider on

a certification form developed by the director for submission to

the  state department with each group of invoices or forms in

claim for payment. The certification form shall indicate the name

of the person, if other than the provider, who signed the

provider's name.

     (c) For a warrant issued in payment of a claim submitted by a

provider, by the handwritten indelible signature of the payee, if

the payee is a natural person; by the handwritten indelible

signature of an officer, if the payee is a corporation; or by

handwritten indelible signature of a partner, if the payee is a

partnership.

     (18) A provider shall comply with all requirements established

under section 111a(1), (2), and (3).

     (19) A provider shall file with the  state department, on

disclosure forms provided by the director, a complete and truthful

statement of all of the following:

     (a) The identity of each individual having, directly or

indirectly, an ownership or beneficial interest in a partnership,

corporation, organization, or other legal entity, except a company

registered  pursuant  according to the securities exchange act of

1934,  chapter 404, 48 Stat. 881  15 USC 78a to 78nn, through which

the provider engages in practice or does business related to claims

or charges against the program. This subdivision does not apply to

a health facility or agency that is required to comply with and has

complied with the disclosure requirements of section 20142(3) of

the public health code, 1978 PA 368, MCL 333.20142. With respect to

a company registered  pursuant to  under the securities exchange

act of 1934,  chapter 404, 48 Stat. 881  15 USC 78a to 78nn, a

provider shall disclose the identity of each individual having,

directly or indirectly, separately or in combination, a 5% or

greater ownership or beneficial interest.

     (b) The identity of each partnership, corporation,

organization, legal entity, or other affiliate whose practice or

business is related to a claim or charge against the program in

which the provider has, directly or indirectly, an ownership or

beneficial interest, trust agreement, or a general or perfected

security interest. This subdivision does not apply to a health

facility or agency that is required to comply with and has complied

with the disclosure requirements of section 20142(4) of the public

health code, 1978 PA 368, MCL 333.20142.

     (c) If applicable to the provider, a copy of a disclosure form

identifying ownership and controlling interests submitted to the

United States department of health and human services in

fulfillment of a condition of participation in programs established

pursuant  according to title V, XVIII, XIX, and XX. To the extent

that information disclosed on this form duplicates information

required to be filed under subdivision (a) or (b), filing a copy of

the form shall satisfy the requirements under those subdivisions.

     (20) If requested by the director, a provider shall supply

complete and truthful information as to his or her professional

qualifications and training, and his or her licensure in each

jurisdiction in which the provider is licensed or authorized to

practice.

     (21) In the interest of review and control of utilization of

services, a provider shall identify each attending, referring, or

prescribing physician, dentist, or other practitioner by means of a

program identification number on each claim or adjustment of a

claim submitted to the  state department.

     (22) It is the obligation of a provider to assure that

services, supplies, or equipment provided to, ordered, or

prescribed on behalf of a medically indigent individual by that

provider will meet professionally accepted standards for the

medical necessity, appropriateness, and quality of health care.

     (23) If any service, supply, or equipment provided directly by

a provider, or any service, supply, or equipment prescribed or

ordered by a provider and delivered by someone other than that

provider, is determined not to be medically necessary, not

appropriate, or not otherwise in accordance with medical assistance

program coverages, the provider who directly provided, ordered, or

prescribed the service, supply, or equipment  shall be  is

responsible for direct and complete repayment of any program

payment made to the provider or to any other person for that

service, supply, or equipment. Services, supplies, or equipment

provided by a consulting provider based upon his or her independent

evaluation or assessment of the recipient's needs is the

responsibility of the consulting provider. This subsection does not

apply to  the repayment by a provider who has ordered a nursing

home or hospital admission of the service billed by and reimbursed

to a nursing home or hospital. This section also does not apply to

a nursing home or hospital unless the nursing home or hospital

acted on its own initiative in providing the service, supply, or

equipment as opposed to following the order or prescription of

another.

     (24) A provider shall satisfy or make acceptable arrangement

to satisfy all previous adjudicated program liabilities including

those adjudicated  pursuant  according to section 111c or

established by agreement between the department and the provider,

and restitution ordered by a court. As used in this subsection,

provider includes, but is not limited to, the provider, the

provider's corporation, partnership, business associates,

employees, clinic, laboratory, provider group, or successors and

assignees. For a nursing home or hospital, "business associates",

as used in this subsection, means those persons whose identity is

required to be disclosed  pursuant to  under section 20142(3) of

the public health code, 1978 PA 368, MCL 333.20142.

     (25) A provider who is a physician, dentist, or other

individual practitioner shall file with the  state department a

complete and factual disclosure of the identity of each employer or

contractor to whom the provider is required to submit, in whole or

in part, payment for services provided to a medically indigent

individual as a condition of the provider's agreement of employment

or other agreement. A provider who has properly disclosed the

required information by filing a form or forms has 30 business days

in which to report changes in the list of identified individuals

and entities. The disclosure required by this subsection may serve

as the provider's authorization for the department to make direct

payments to the employer.

     (26) As a condition of receiving payment for services rendered

to a medically indigent individual, a provider may enter, as an

employee, into agreements of employment of the type described in

subsection (25) only with an employer who has entered into an

agreement as described in subsection (27).

     (27) An employer described in subsection (25) shall enter into

an agreement on a form prescribed by the department, in which, as a

condition of directly receiving payment for services provided by

its employee provider to a medically indigent individual, the

employer agrees to all of the following:

     (a) To require as a condition of employment that the employee

provider submit, in whole or in part, payments received for

services provided to medically indigent individuals.

     (b) To advise the department within 30 days after any changes

in the employment relationship.

     (c) To comply with the conditions of participation established

by this subsection and subsections (6) to (19)  , and (21).

     (d) To agree to be jointly and severally responsible with the

employee provider for any overpayments resulting from the

department's direct payment under this section.

     (e) To agree that disputed claims relative to overpayments

shall be adjudicated in administrative proceedings convened

pursuant to  under section 111c.

     (28) If a provider who is a nursing home intends to withdraw

from participation in the title XIX program, the provider shall

notify the department in writing.  However, the  The provider shall

continue to participate in the title XIX program for each patient

who was admitted to the nursing home before the date notice is

given under this subsection and who is or may become eligible to

receive medical assistance under this act.

     (29) A provider shall protect, maintain, retain, and dispose

of patient medical records and other individually identifying

information in accordance with subsection (6), any other applicable

state or federal law, and the most recent provider agreement.

     (30) At a minimum, if a provider is authorized to dispose of

patient records or other patient identifying information, including

records required by subsection (6), the provider shall ensure that

medical records that identify a patient and other individually

identifying information are sufficiently deleted, shredded,

incinerated, or disposed of in a fashion that will protect the

confidentiality of the patient's health care information and

personal information. The department may take action to enforce

this subsection. If the department cannot enforce compliance with

this subsection, the department may enter into a contract or make

other arrangements to ensure that patient records and other

individually identifying information are disposed of in a fashion

that will protect the confidentiality of the patient's health care

information and personal information and assess costs associated

with that disposal against the provider. The provider's

responsibilities with regard to maintenance, retention, and

disposal of patient medical records and other individually

identifying information continue after the provider ceases to

participate in the medical assistance program for the time period

specified under this section.